Failure to Prevent Accident Hazards Related to Smoking Paraphernalia
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards by allowing multiple residents to possess unauthorized lighters, despite a policy prohibiting such items in resident rooms. Five residents were found to have lighters in their possession, and staff interviews revealed that there was no written procedure for handling smoking paraphernalia. Staff often handed lighters to residents during smoke breaks and did not consistently retrieve them afterward, resulting in residents retaining lighters in their rooms. Several staff members and residents confirmed that lighters were not always collected after use, and there was a general lack of clarity and enforcement regarding the facility's smoking policy and procedures. One resident, a female with a history of traumatic amputation, dementia, and diabetes, suffered second-degree burns to her right foot after using a lighter to burn a gauze bandage that was too tight. The resident had previously been assessed as safe to smoke unsupervised, with no cognitive impairment noted on her BIMS assessment. On the night of the incident, the resident requested assistance with her bandage, but staff response was delayed. During this time, the resident attempted to remove the bandage herself using a lighter, which resulted in the bandage and her foot catching fire. Staff responded to the fire, and emergency services were called, but the resident initially refused treatment. Interviews with staff and residents indicated that the facility's policy prohibiting lighters in resident rooms was not consistently followed. Staff admitted to not always retrieving lighters after smoke breaks, and residents reported frequently having lighters in their possession. The facility did not have a written smoking procedure, and staff were unclear about the process for supervising residents during smoke breaks and managing smoking paraphernalia. The lack of adherence to policy and absence of clear procedures directly contributed to the incident and the presence of accident hazards in the facility.
Removal Plan
- Resident was sent to the emergency department for assessment after initially refusing any treatment; placed on 1:1 observation; psychiatric services referral made.
- All other residents who smoke, including those discovered with cigarette lighters, had a skin assessment completed with no visible signs of injury related to cigarettes or lighters.
- Facility administrator, director of nurses, and regional compliance swept all resident rooms for items not allowed in resident's rooms and to check for cigarette lighters; removed offending items and completed a log of items found and removed.
- Facility administrator/DON/Compliance nurse will keep a log of any medications/items (including cigarette lighters) not allowed found at bedside during champion rounds; any items discovered will be reported to the DON/Administrator at the time of discovery.
- Regional Compliance Nurse in-serviced the DON and administrator on items not allowed; if a resident is found with a cigarette lighter, the item is to be removed from the room.
- Smoke breaks are to be supervised by facility staff assigned to scheduled smoke breaks; residents will not be given a lighter to keep during smoke break; staff will light the cigarette for the resident and return the lighter to the smoking lock box after use.
- A log will be placed in the lock box to verify the count of cigarette lighters at the start and end of the smoke break; facility staff education provided on the new process.
- Facility administrator, director of nursing, or compliance nurse will review the lighter log for discrepancies.
- Staff were given a copy of the new process and verbal checks by DON and compliance nurses are being conducted each shift to verify understanding.
- Regional Compliance Nurse educated the DON/Administrator that this incident and any other incident related to smoking paraphernalia (including cigarette lighters) to be reviewed monthly by the QAPI committee; Area Director of Operations or Regional Compliance Nurse will attend QAPI committee meetings and verify continued compliance.
- Nursing staff education was begun by the Director of Nurses to ask residents returning from being out of facility to smoke if they have cigarette lighters in possession; if found, re-educate and take items or return them to family; incidents to be reported to DON/Admin immediately.
- Facility staff have been given written fact sheets to keep with them during the learning process and verbal questioning is being done of three staff members at least 5 times weekly and PRN.
- Facility completed education/notification in form of an email to all RPs of residents with a list of items not allowed in residents rooms (including cigarette lighters) and the smoking policy; physical copy to be mailed out to resident RPs; for all future residents, list of items not allowed in room will be provided upon admission as part of the admission packet.
- Education/in-service begun for all staff by facility director of nursing to reiterate the policy of items not allowed in residents rooms (including cigarette lighters) and smoking policy, by phone, COVR, and in person; staff will not be able to return to work until education has been provided; signature or acknowledgement of this education will be confirmed by an audit list; monitored for continuous compliance including new hires.
- Facility provided a copy of list of items not allowed (including cigarette lighters) and the smoking policy to residents and kept a signed copy; residents unable to sign confirmed by two witnesses; signed copy scanned into resident's electronic medical record.
- A sign was placed at the front door of the facility with the items not allowed (including cigarette lighters) and the smoking policy for reference and education.
- The physical environment of all residents was observed (closet, nightstands, storage containers) to ensure no cigarette lighters were retained in their room by the facility administrator, director of nurses, and regional compliance nurse.
- MD was notified of IJ F689 Free of Accidents/Hazards/Supervision/Devices.
- All facility staff were educated by the director of nursing that no residents may be left alone on the smoking patio; staff are to light the resident cigarettes and return lighter to the receptacle for safe keeping; facility administrator will review the lighter logs for compliance.
- All in-service education will be completed by new hires at orientation and before assuming duties in the facility; verified by Administrator, Director of Nurses, or Regional Compliance Nurse.
- Facility department heads or weekend manager on duty will conduct champion rounds in every resident room and look for items not allowed per written company guidelines (including cigarette lighters); remove items if identified and report to DON/Administrator; monitoring to start.
- Regional Compliance Nurse will monitor during weekly visits and ask DON and Administrator what items are not allowed in residents room (including cigarette lighters) and what to do if any are identified; will be questioned about the smoking policy and any identified violations; monitoring to continue for at least 8 weeks and PRN thereafter.
- Administrator/DON will assess five resident rooms for posted items not allowed (including cigarette lighters), to ensure residents do not have any items not allowed in room.
- Regional Compliance Nurse will assess for compliance with posted items not allowed (including cigarette lighters) once weekly by verification of completion of facility assigned monitoring and visual verification of five rooms each week; monitoring to continue for at least 8 weeks and PRN thereafter.